Why Complex Care?

Policymakers, payers, and providers of health care are increasingly focused on improved models of care for high-need, high-cost patients, a relatively small group of individuals who account for a significant portion of health care costs, and are very often high utilizers of other systems as well (e.g., criminal justice, housing assistance). In addition to their complex medical and/or behavioral health needs, these patients often face a number of social and economic challenges that further complicate their health outcomes-including, for example, lack of employment, housing instability, social isolation, and food insecurity.

PROGRAM

What We Do

Redwood Community Health Coalition is running a learning collaborative with six of its community health centers to develop and pilot a standard care management training program for the clinics’ multi-disciplinary complex care teams. The trainings focus on the following:

  • Developing the core skills needed to provide effective complex care management;
  • Identifying a standard set of social determinants of health metrics to track, and training on how to incorporate SDH data collection into health center workflows; and
  • Ensuring health centers are prepared for rollout of California’s Medicaid Health Homes (Section 2703) in 2017.

Who We Serve

Patients with complex needs are defined as Medi-Cal beneficiaries having one or more of the following characteristics:

  • Serious mental illness or substance use disorders;
  • High emergency department or hospital utilization;
  • Multiple prescriptions;
  • Chronic illnesses and pain; and
  • Homelessness

Funders

This project is funded by the Robert Wood Johnson Foundation.

Project Timeline

May 2016 through April 2018

MEASURES & GUIDELINES

Evaluation

The project team will conduct an initial qualitative analysis to determine how learning collaborative trainings impacted participants’ abilities to serve complex patients. In addition to interviewing representatives from three participating health centers, RCHC staff will also interview representatives from three RCHC health centers that did not participate in the collaborative. We will conduct in-depth open-ended interviews about how each site cares for complex patients. We will compare responses and issues raised between both collaborative and non-collaborative health centers.

Additionally, RCHC will work with Rutgers staff to design a more robust evaluation (including a data collection and analysis strategy) that can be carried out by RCHC at project end.

PERFORMANCE/RESULTS

Results of this project will be available in April 2018.

PROJECT PARTNERS

Health Centers:

  • Alexander Valley Healthcare
  • Marin Community Clinics
  • Petaluma Health Center
  • Santa Rosa Community Health
  • Sonoma Valley Community Health Center
  • West County Health Centers

Strategic Partners:

  • Robert Wood Johnson Foundation
  • Center for Health Care Strategies
  • Partnership HealthPlan

Evaluation Assistance:

  • Rutgers University

PROJECT CONTACT

For more information, please contact Claire Cain

ALIGNMENT WITH OTHER INITIATIVES

  • HRSA HCCN Grant (Social Determinants of Health)
  • CMSP Grant (Social Determinants of Health)
  • NACHC BSCF Grant (Social Determinants of Health)
  • Medicaid Health Homes Section 2703
  • Partnership HealthPlan’s Intensive Outpatient Case Management project

ADDITIONAL RESOURCES AND COMPANION DOCUMENTS